Cardiogenic Shock - June_2017

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Text of Cardiogenic Shock - June_2017

  • Frederik Meijer

    Heart & Vascular Institute

  • Frederik Meijer Heart & Vascular Institute

    Cardiogenic Shock

    for the Intensivist

    Michael Dickinson, MD, FACC, FHFSA

    Section Chief, Advanced Heart Failure

    Medical Director for Heart Failure and Heart Transplant

    Richard DeVos Heart & Lung Transplant Program

    Frederik Meijer Heart & Vascular Institute

    Spectrum Health

  • Frederik Meijer Heart & Vascular Institute

    Disclosures

    None relevant to this presentation.

    3

  • Frederik Meijer Heart & Vascular Institute

    Presented to rural ER with chest

    pain

    Suffered VF arrest in the ER x 2

    Resuscitated back to a pulse

    after 15 minutes of CPR.

    Intubated, on ventilator and

    neurologic status unclear.

    Cooling protocol initiated and

    transferred to the Meijer Heart

    Center for cardiac cath.

    51 yr old man with chest pain

    LAD was then stented.

  • Frederik Meijer Heart & Vascular Institute

    Cardiac Catheterization acute stent thrombosis

    Recurrent VF

    arrests and

    hypoperfusion

    despite very high

    dose pressor and

    inotrope doses.

    Maximal medical

    support but the

    odds of survival

    were now very

    low.

  • Frederik Meijer Heart & Vascular Institute

    Shock Team activation

  • Frederik Meijer Heart & Vascular Institute

    Clinical Course

    Cooling protocol performed.

    Clinical condition worsened.

    Artificial lung added onto circuit

    (ECMO)

  • Frederik Meijer Heart & Vascular Institute

    Clinical Course

    Cooling protocol performed.

    Clinical condition worsened.

    Artificial lung added onto circuit.

    After 4 days was weaned from

    artificial lung and then off

    tandem heart.

    Cardiac function normalized.

    Neurologic function normalized.

    He is fully functional now.

    He works full time and supports his

    family.

  • Frederik Meijer Heart & Vascular Institute

    What is a changin?

    Acute mechanical circulatory support (ECMO, Impella, etc)

    Failure to rescue

    Recognize and treat the variable hemodynamics

    9

  • Frederik Meijer Heart & Vascular Institute

    38 year old man admitted for heart failure. Known NIDCM

    5 pm: Routine

    admission orders. Lasix

    40 mg IV.

    2 am: BP low. RN calls

    PA. IVF bolus given.

    2:20 am: Dyspneic,

    hypoxemic, hypotension (Dopamine)

    3:15 am: Cardiac

    arrest and died.

    10

  • Frederik Meijer Heart & Vascular Institute

    38 year old man admitted for heart failure. Known NIDCM

    5 pm: Routine

    admission orders. Lasix

    40 mg IV.

    2 am: BP low. RN calls

    PA. IVF bolus given.

    2:20 am: Dyspneic,

    hypoxemic, hypotension (Dopamine)

    3:15 am: Cardiac

    arrest and died.

    11

  • Frederik Meijer Heart & Vascular Institute

    What causes failure to rescue?

    Not detected

    Not recognized

    Not acted upon

    Not escalated

    12

    When patient instability / decline / failure is:

  • Frederik Meijer Heart & Vascular Institute

    Hospital Mortality Heart Failure Admissions @ SH

    2.80%4.40% 5.20%

    8.20%

    15.60%17.40%

    26.70%

    0.00%

    5.00%

    10.00%

    15.00%

    20.00%

    25.00%

    30.00%

    Nesiritide Nes + Ntg Nitroglycerin Dobutamine Nes + Mil Milrinone Nes + Dob

  • Frederik Meijer Heart & Vascular Institute

    What does this data tell us?

    If a clinician feels the

    need to use inotropes

    that patient has just

    become high risk

    (>8% in hospital

    mortality).

    Once you use more

    than one vasoactive

    your patient has

    become very high risk.

    2.80%4.40% 5.20%

    8.20%

    15.60%17.40%

    26.70%

    0.00%

    5.00%

    10.00%

    15.00%

    20.00%

    25.00%

    30.00%

    Nesiritide Nes + Ntg Nitroglycerin Dobutamine Nes + Mil Milrinone Nes + Dob

  • Frederik Meijer Heart & Vascular Institute

    What about with STEMI? Predictors of Survival

    Predictor Yes (3yr/6 yr) No (3 yr/6 yr) p

    Systemic hypoperfusion not rapidly reversed with IABP

    20.6/16.5 43.3/32.9 =1.9 13.8/13.8 37.9/29.5 0.0002

    LVEF < 25% 29.9/19.2 50.8/40.9 0.002

    Prior MI 22.9/15.3 40.2/31.0 0.005

    PCWP >=25 28.3/22.0 43.8/33.4 0.01

    No lytic therapy at index MI 28.8/18.6 39.3/31.4 0.016

    Shock on admission 24.8/12.4 36.7/28.5 0.016

    Hx hypertension 30.5/18.2 39.6/34.0 0.027

    Multivessel disease 37.6/28.2 64.5/49.2 0.044

    Age >=75 20.6/20.6 38.2/27.6 0.06315

  • Frederik Meijer Heart & Vascular Institute

    What about with STEMI? Predictors of Survival

    Predictor Yes (3yr/6 yr) No (3 yr/6 yr) p

    Systemic hypoperfusion not rapidly reversed with IABP

    20.6/16.5 43.3/32.9 =1.9 13.8/13.8 37.9/29.5 0.0002

    LVEF < 25% 29.9/19.2 50.8/40.9 0.002

    Prior MI 22.9/15.3 40.2/31.0 0.005

    PCWP >=25 28.3/22.0 43.8/33.4 0.01

    No lytic therapy at index MI 28.8/18.6 39.3/31.4 0.016

    Shock on admission 24.8/12.4 36.7/28.5 0.016

    Hx hypertension 30.5/18.2 39.6/34.0 0.027

    Multivessel disease 37.6/28.2 64.5/49.2 0.044

    Age >=75 20.6/20.6 38.2/27.6 0.06316

  • Frederik Meijer Heart & Vascular Institute

    So we can say:

    NIDCM: Patients who need inotropes (esp > 1 moderate dose)

    are high risk. Even if they respond and improve, they are at

    risk for the future.

    STEMI: Initiate intentional meaningful surveillance:

    If shock doesnt rapidly reverse with IABP,

    Baseline Cr >=1.9,

    Very low EF (25 (high LVEDP at cath)

    Advanced age, prior MI, etc

    17

  • Frederik Meijer Heart & Vascular Institute

    What is optimal care?

    Detect

    Vitals

    Feel (warm/cold)

    Look (JV pressure)

    Watch urine output, mentation, etc..

    Recognize

    Inotropes = risk (two = high risk)

    Unstable after PCI = risk

    Tachycardia, poor urine output

    Act

    Intensive surveillance

    Hemodynamic assessment and treatment.

    Escalate

    Call for help.

    Shock call -mechanical circulatory support

    18

    Most of the time a code is called, we should view it as a

    failure. How did we not act before it got to this point?

  • Frederik Meijer Heart & Vascular Institute

    19

  • Frederik Meijer Heart & Vascular Institute

    Hemodynamic: Not algorithmic

    20

    Filling: Enough? Too much?

    Pump: Contractile strength / cardiac output?

    Vascular tone: Vasoconstricted or vasodilated

    (vasoplegia)

  • Frederik Meijer Heart & Vascular Institute

    Vasoplegia

    Low SVR state

    Not well understood but

    likely mediated by

    inflammatory mediators

    Common in cardiorenal

    syndrome

    Common after

    resuscitation

    21

  • Frederik Meijer Heart & Vascular Institute

    How do you handle vasoplegia?

    22

    1. Stop vasodilators.

    2. Give vasoconstrictors.

    3. Correct acidosis.

    4. Give them as much

    cardiac output as you

    can. (Concept of not

    enough CO)

    5. Methylene blue

  • Frederik Meijer Heart & Vascular Institute

    But which drug?

    Dopamine:Mostly a vasoconstrictor.

    Tachycardia

    Norepinephrine: Mostly a vasoconstrictor.

    Phenylephrine: Vasoconstrictor.

    Milrinone:Inodilator (inotrope plus

    vasodilator)

    Dobutamine: Inodilator (mostly inotrope)

    Epinephrine:Inoconstrictor (inotrope plus

    vasoconstrictor)

    Nitroprusside: Arterial Vasodilator

    Nitroglycerin: Venodilator23

  • Frederik Meijer Heart & Vascular Institute

    How about in cardiac surgery?

  • Frederik Meijer Heart & Vascular Institute

    Inotrope level predicted mortality

    0%10%20%30%40%50%60%70%80%

    Mortality

    Mortality

  • Frederik Meijer Heart & Vascular Institute

    Why did they look at this data?

    Early in our experience, we had no

    formal insertion criteria. Patients

    were placed on VAD support

    after "maximal inotropic support

    and an IABP failed to improve

    cardiac hemodynamics,

    particularly cardiac output. As a

    consequence of this, VADs were

    being placed at the surgeon's

    discretion and results were poor;

    the devices were being placed

    late and the incidence of MOSF

    was high. ZERO % survival

    VAD Insertion

    Formula:If 2 or more high

    dose inotropes and

    ongoing

    cardiogenic shock,

    then place the

    VAD.

  • Frederik Meijer Heart & Vascular Institute

    Did it make a difference?

    Before After

    Placed within 3 hours of

    first attempt to wean from

    CPB

    22% 85%

    Placed late (>3 hours) 78% 15%

    MOSF 78% 15%

    Able to be weaned 22% 80%

    Survival to discharge 0% 40%

  • Frederik Meijer Heart & Vascular Institute

    Did it make a difference?

    Before After

    Placed within 3 hours of

    first attempt to wean from

    CPB

    22% 85%

    Placed late (>3 hours) 78% 15%

    MOSF 78% 15%

    Able to be weaned 22% 80%

    Survival to discharge 0% 40%

  • Frederik Meijer Heart & Vascular Institute

    What are the lessons?